ly universal, estimated at 98.7 percent of the
ered substandard, particularly in the south.
population. The system provides primary
They lack not just modern technology, but
health care, including general health and pedi-
basic goods and services; and overcrowding is
atric care, outpatient and inpatient surgery,
widespread. Conditions are frequently unsani-
emergency and acute care, long-term disease
tary. For example, one of the largest public hos-
management, and prescription drugs (al-
pitals in Rome was recently found to have
though some drugs may require a copayment).
garbage piled in the hallways, unguarded
Many mental health services, particularly out-
radioactive materials, abandoned medical
records, and staff smoking next to patients.108
patient services, are excluded, as is cosmetic
surgery.112
Private hospitals are considered much better
and some regions have contracted with private
The federal government provides each
hospitals to treat NHS patients.
region with a block grant. The money is not
Dissatisfaction with the Italian health care
earmarked: the region decides how to use it.
system is extremely high, by some measures the
The block grant itself is based primarily on a
highest in Europe.109 In polls, Italians say that
region's population with some consideration
given to other factors such as the population's
their health care system is much worse than
demographics. Regions may use their own
that of other countries and give it poor marks
Spanish patients
funds to supplement federal monies.
for meeting their needs. Roughly 60 percent of
cannot choose
Not surprisingly, health care spending
Italians believe that health care reform is
varies widely from region to region. The differ-
"urgent," and another 24 percent believe it is
their physicians,
ences in expenditures, as well as in spending
"desirable." In general, Italians believe that
either primary
priorities, lead to considerable variance in the
such reform should incorporate market-based
care or
availability of health resources. For example,
solutions. More than two-thirds (69 percent)
Catalonia has more than 4.5 hospital beds per
believe that giving patients more control over
specialists.
1,000 residents, while Valencia has just 2.8.113
health care spending will improve the system's
quality. And 55 percent believe that it should
Spanish patients cannot choose their physi-
be easier for patients to spend their own money
cians, either primary care or specialists. Rather,
on health care.110
they are assigned a primary care doctor from a
list of physicians in their local community. If
However, given the general dysfunction of
more specialized care is needed, the primary
the Italian political system, and the entrenched
care physician refers patients to a network of
opposition of special interest groups, substan-
specialists. Unlike U.S. managed care, it is not
tial reform is not likely anytime soon.
possible to go "out of network" unless the
patient has private health insurance (see
Spain
below). This has sparked an interesting phe-
nomenon whereby sick Spaniards move in
order to change physicians or find networks
Spain's national health care system oper-
with shorter waiting lists.
ates on a highly decentralized basis, giving pri-
Waiting lists vary from region to region but
mary responsibility to the country's 17 regions.
are a significant problem everywhere. On aver-
The Spanish Constitution guarantees all citi-
age, Spaniards wait 65 days to see a specialist,
zens the "right" to health care, including equal
and in some regions the wait can be much
access to preventive, curative, and rehabilitative
longer. For instance, the wait for a specialist in
services; but responsibility for implementing
the Canary Islands is 140 days. Even on the
the country's universal system is being
mainland, in Galacia, the wait can be as long as
devolved to regional governments. The degree
81 days. For some specialties the problem is far
and speed of devolution is uneven, however,
worse, with a national average of 71 days for a
with some regions only recently achieving
maximum autonomy.111
gynecologist and 81 days for a neurologist.114
Coverage under the Spanish system is near-
Waits for specific procedures are also lengthy.
14